Richard B. Price, MD

Release of Information Authorization Form

Phone: 913-491-8319

 
I, (Patient/Guardian Name)
hereby authorize Richard B. Price, MD to release protected health information to:
Records Desired




Patient/Guardian Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
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